Provider Demographics
NPI:1134121007
Name:FUNK, SIDNEY A (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:A
Last Name:FUNK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 JOHNSON FERRY RD NE
Mailing Address - Street 2:#720
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1626
Mailing Address - Country:US
Mailing Address - Phone:404-252-3898
Mailing Address - Fax:404-843-0719
Practice Address - Street 1:980 JOHNSON FERRY RD NE
Practice Address - Street 2:#720
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1626
Practice Address - Country:US
Practice Address - Phone:404-252-3898
Practice Address - Fax:404-843-0719
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011333174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0008716CMedicaid
GA0008716CMedicaid